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Run: Head Start Home Visit Documentation Form

Track each Head Start home visit in one place, including participants, parent-child activities, health and nutrition education, observations, and next-step g...

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Visit Details

Visit Date (required)

Select the date the home visit occurred.

Start Time

Optional: record the time the visit began.

End Time

Optional: record the time the visit ended.

Visit Type (required)

Choose the type of home visit documented.

Staff Member Completing This Form (required)

Enter the name or identifier of the staff member documenting the visit.

Participants and Family Engagement

Who Participated in the Visit? (required)

Select all participants present during the visit.

Parent-Child Interaction Activities (required)

Describe the activities used to support parent-child interaction, such as reading, play, routines, or learning activities.

Family Engagement Observations

Record notable observations about engagement, strengths, or barriers observed during the visit.

Health and Nutrition Education

Was Health Education Provided? (required)

Select yes if any health education was delivered during the visit.

Was Nutrition Education Provided? (required)

Select yes if any nutrition education was delivered during the visit.

Health Education Topics

Select the health topics discussed during the visit.

Nutrition Education Topics

Select the nutrition topics discussed during the visit.

Education Summary

Summarize the key points, resources, or materials shared. Avoid collecting unnecessary PII.

Child and Family Needs

Child Observations

Record relevant observations about the child's development, behavior, or participation during the visit.

Family Strengths

Describe strengths, protective factors, or successful routines observed during the visit.

Concerns or Barriers

Document any concerns or barriers affecting participation, follow-through, or family goals.

Referrals or Resources Provided

List any referrals, resources, or follow-up supports provided during the visit.

Next Visit Goals and Follow-Up

Primary Goal for the Next Visit (required)

Describe the main goal to address at the next home visit.

Next Visit Focus Area (required)

Choose the primary focus for the next visit.

Follow-Up Actions Needed

Describe any actions to complete before the next visit.

Attestation

I confirm this documentation is accurate to the best of my knowledge. (required)

Required attestation for the audit trail.

Yes No N/A

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